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• FEE $35.00
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CITY OF LA QUINTA /
78-495 Calle Tampico, P. O.Box 1504, La Quinta, CA 92253
HOME OCCUPATION PERMIT
Read each condition listed on the attachment to this form to see if
the proposed activity can comply with the City's Home Occupation
Regulations.
BUSINESS NAME M. 4, 601Vs re C7 -101V PHONE —6Z
PROPERTY OWNER /L//�� ►//N L . 57_77 A PHONE /,1;7:6
PROPERTY ADDRESS - / O .4YcNI 0 /N
MAILING ADDRESS 77. Box272-F-27 657/NTA C4 QZ2
TYPE OF RESIDENCE (single, multiple, mobil home, etc.) SJ N (r.,L a7
TYPE OF BUSINESS (?AJ7 e70.4e__
BRIEF DESCRIPTION OF HOW THE BUSINESS WILL OPERATE S
/ /VD /S .i' qyi ,47- -rH&- /fD"e
NUMBER OF PERSONS INVOLVED IN BUSINESS O/l/F
LIST NAME OF PERSONS EMPLOYED ND N�
SQUARE FOOTAGE OF USABLE FLOOR AREA
IN HOUSE (EXCLUDE GARAGE) —L—S-77
LOCATION AND SQUARE FOOTAGE OF AREA 13ED�04M — //0
OF BUSINESS ACTIVITY IN HOME
(EXAMPLE, "BEDROOM -125 S.F.")
DESCRIPTION OF MACHINERY, EQUIPMENT, AND SUPPLIES BEING USED IN THE
BUSINESS OPERATION 7'�FL.e�Oh 01V&', FW X, 60~117-ZrJZ
I HAVE READ, UNDERSTAND, AND AGREE WITH THE CONDITIONS BY WHICH A
HOME 0 UPAT�ON ALLOWED (CONDITIONS ATTACHED).
APPLICAN SIGNATURE DATE
IF APPLICANT IS OTHER THAN PROPERTY OWNER, AUTHORIZATION OF OWNER
OR AGENT IS REQUIRED.
N%A-
OWNER/AGENT SIGNATURE DATE
IMPORTANT: FALSE OR MISLEADING INFORMATION SHALL BE GROUNDS FOR
DENYING YOUR HOME OCCUPATION; FAILURE TO COMPLY WITH CONDITIONS
LISTED ON THE ATTACHED PAGE SHALL BE GROUNDS FOR REVOCATION OF
PERMIT.
Bj!jj4inq and Safety Department
lyt APPROVED DENIED CONDITIONS ATTACHED
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1996
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78-495 CALLE TAMPICO — LA OUINTA, CALIFORNIA 92253 - (619) 777-7000
FAX (619) 777-7101
Every employer who applies for any license or a renewal of any
license for a business issued pursuant to Section 37101 of the
Government Code or Section 7284 of the Revenue and Taxation Code
shall complete and sign a declaration that states the following:
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury, one of the following
declaration:
I have and will maintain a certificate of consent to self -
insure for worker's compensation, as provided by Section 3700 for
the duration of any business activities conducted for which this
license is issued.
I have and will maintain worker's compensation insurance, as
required by Section 3700 for the duration of any business
activities conducted for which this license is issued.
• My worker's compensation insurance carrier and policy number:
Carrier: 5T,4T5 FVAJ-
Policy Number: z9 — 9G&
A "COPY" OF THE POLICY SHOWING
EXPIRATION DATE FOR WORKMEN'S COMPEN!
THIS APPLICATION.
)F .COVERAGE AND
FIRED TO PROCESS
I certify that in the performance of any business activities
for which this license.is issued I shall not employ any person in
any manner so as to become subject to the •worker's compensation
laws of California, and agree that if I should become subject to
the worker's compensation provisions of Section 370.0.
.Date: 13 —f4; Applicant: �---f
WARNING: Failure to secure .workman's c mpensation coverage is
unlawful, and shall subject an employer to criminal penalties and
civic fines up to $100,000. In addition to the cost of
compensation, damages as provided for in Section 3706 of the Labor
Code, interest, and attorney's fees.
bus.fac
A.
MAILING ADDRESS - P.O: BOX 1504 - LA OUINTA, CALIFORNIA 92253 ��
Y
STATE P.O. BOX 420807, SAN FRANCISCO, CA 94142-0807
COMPENSATION
•W INSURANCE
F V N D`" CERTIFICATE OF WORKERS' COMPENSATION INSURANCE
1 .. POLICY NUMBER:
1996 CERTIFICATE EXPIRES: 2 29-- g 6 UNIT 00 i % 57
COO �IACTM TA
.3ax 2600:0.
J013t LIC. 0343335'
L INCCPT. DAM 01-01_96
DIS` RIC`', OFFICE-AiVk.RaIly
This is to certify that we have issued'a valid Workers' Compensation insurance policy in a form approved by the California
Insurance Commissioner to the employer named below for the policy period indicated.
This,policy is not subject to cancellation by the Fund except upon ten days' advance written notice to the employer.
We will also give you TEN days' advance notice should this policy be cancelled prior to its normal expiration.
This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the
policies listed herein. Notwithstanding any requirement, term, or condition of any contract or other document with
respect to which: this certificate of insurance may be issued. or• may pertain„ the insurance afforded by the policies
described herein is subject to all the terms, exclusions and conditions of such policies.
PRESIDENT
G.i .JYi;Rf LIA8I ITY L1. j1T �.P�CLUDING EFENSE' COSPS: Px tO00,000 PER CCCUR .. �
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March 7, 1996
4.
78-495 CALLE TAMPICO — LA GIUINTA, CALIFORNIA 92253 - (619) 777-7000
FAX (619) 77777101
Certified Mail
.Marvin Jordan
M L Construction
P. O. Box 228
La Quinta, CA 92253
Dear Mr. Jordan:,
The Finance Department brought to my attention that you have changed your home address. Because
of the change of address, you need to reapply for another. Home Occupation Permit in order to
renew your Business License with the City.
Please complete the enclosed form, (first and third pages) and return the permit with a check for
$35.00. When we receive the permit and check, I will schedule you for an inspection of your work
area, which only takes a few minutes. Once the Home Occupation is approved at your new address,
the Finance Department will process your business license.
Your 1996 Business License will -remain invalid until the Home Occupation Permit requirements are
met. If you have any questions, please call me at (619) 777-7050:
Respectfully,
Ellie Shep erd
Code Compliance
Enclosure
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MAILING ADDRESS P.O. BOX 1504 - LA OUINTA, CALIFORNIA 92253